{"ref":"LA-HH-CP-01","title":"Plan of Care, Plan of Care Review, and Continuation of Services","category":"Service delivery","summary":"Sets out how each patient's individualized plan of care is developed by an RN or appropriate therapist, signed by the authorized healthcare provider within a timely manner (the Agency's target is within 14 days, never later than 60 days), followed exactly, reviewed by the authorized healthcare provider with the Agency's professional personnel at least once every two months (and, if the Agency is Medicare-certified, at least once every 60 days), updated by the RN as needed or at least every 60 days, and renewed for continuation of services, with each plan in the record within seven days. It covers the content of the plan, patient participation, and tracking signatures and review dates.","inShort":["Give care only as the plan of care and the provider's orders say.","Involve the patient in setting goals and in every change to the plan.","The provider signs the plan within 14 days, and never later than 60 days.","The plan is reviewed with the provider at least every 60 days.","Report a missed visit to the clinical manager the same day.","LPNs may not write or change the plan of care."],"primaryCitation":"LAC 48:I §9123.C","citations":["LAC 48:I §9123.B.2","LAC 48:I §9123.C","LAC 48:I §9123.C.1","LAC 48:I §9123.C.2","LAC 48:I §9123.C.3","LAC 48:I §9123.D","LAC 48:I §9103.K.2.c","LAC 48:I §9103.D.3.c","LAC 48:I §9125.A.4","LAC 48:I §9125.A.5","LAC 48:I §9129.C.2","LAC 48:I §9127.A.1.c","LAC 48:I §9127.A.1.d"],"federalCitations":["42 CFR §484.60","42 CFR §484.60(a)","42 CFR §484.60(b)","42 CFR §484.60(c)","42 CFR §409.43"],"surveyorAsks":["Show me this patient's current plan of care. When was it signed by the authorized healthcare provider?","When was the plan of care last reviewed, and when is the next review due?"],"forms":[{"ref":"LA-HH-CP-01-A","title":"Plan of Care and Orders Tracking Log"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (LAC 48:I §9123.C)","5. Developing the Plan of Care","6. Content of the Plan of Care","7. Signature by the Authorized Healthcare Provider","8. Giving Care Under the Plan","9. Review and Revision of the Plan of Care","10. Continuation of Services","11. Tracking","12. Responsibilities","13. Records and Compliance Monitoring","14. Staff Training","15. References","16. Related Policies and Forms","17. Approval","18. Revision History"],"version":"1.0","sample":false,"pack":"la-hha","state":"Louisiana","service":"Home health","guides":[{"path":"/guides/home-health-agency-policies/","h1":"What policies and procedures are required for home health agencies?"},{"path":"/guides/home-health-conditions-of-participation/","h1":"Home health Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}